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Applicants Relation to
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Religion *
Caste *
Occupation and Income Details of Applicants Family * (Please fill the sections as applicable)
Income from Salary/Pension
Type of Occupation Father Mother Spouse
Central Government [ ] [ ] [ ]
State Government [ ] [ ] [ ]
Private Sector [ ] [ ] [ ]
PSU [ ] [ ] [ ]
Armed forces [ ] [ ] [ ]
Others (Specify)
Occupation Details Father Mother Spouse
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If Pensioner, date of
retirement (dd/mm/yyyy)
Income from Business
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Owner of property Father [ ] Mother [ ] Minor [ ]
Location
Area (Yards / Sq. Metres / Acres /
Hectares)
Type of agricultural land Irrigated [ ] Dry crop [ ]
Area of irrigated land (Yards /
Sq. Metres / Acres / Hectares)
a) Percentage of irrigated
land as per constitutional
ceiling under the state land
ceiling act formula
b) If you own both irrigated
and dry land, percentage
of irrigated land as per
constitutional ceiling under
the state land ceiling act
formula
As per a) total irrigated land as
a percentage as calculated by
the land ceiling act formula
Cultivation details
Type of cultivation Crop [ ] Fruits [ ]
Location
Cultivated Area (Yards / Sq.
Metres / Acres / Hectares)
Details of land/building in urban area
Location of property
Details of property
Current use of property
Total Annual Family Income
from all sources excluding
salary and agricultural income
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Have you paid wealth tax
Yes [ ] No [ ]
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Self-Declaration
I ______________________________________________son/daughter of ________________
_________________________ aged ________ occupation ________________________
hereby declare that the information provided above is true and correct to the best of my
knowledge, information and belief. I fully understand the consequence of giving false
information. If the information as given above is found to be false, I shall be liable to
prosecution and punishment under section 199 and 200 of IPC 1960 and/or any other law
applicable thereto.
Proof of caste for self School leaving certificate mentioning caste / Bonafide
3. certificate (mentioning caste) issued by school / self attested Xerox of caste certificate
/ If uneducated birth registration extract / Caste and residence certificate issued by [ ]
Sarpanch/Local Police/Corporator
Income proof Income tax return for previous 3 financial years, if applicant is salaried
5. or self employed or businessman / Income certificate from Tahsildar for 3 years, if [ ]
applicant is farmer or labourer / Affidavit mentioning income for last 3 years
2. If proof of fathers caste not available, a relatives caste certificate and genealogical
affidavit with details of relation to relative [ ]
3. If applicant migrated from other state/ district, then caste certificate of applicants
father issued by competent authority in that state/district [ ]
If married women,
4. a. Proof of caste before marriage, as prescribed in point no. 3
[ ]
b. Proof of marriage- marriage registration certificate and name change
notification in gazette